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High Acuity > Burn Injury-High Acuity > Flashcards

Burn Injury-High Acuity Flashcards

1
Q

Burn Injury

A

tissue injury caused by

  • thermal
  • electric
  • chemical
  • radiation
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2
Q

Which 2 populations are at highest risk for burn injury?

A
  • Children (less than 4yrs)

- Older adults (greater than 65 yrs)

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3
Q

In children, which burn injuries are most common?

A

scald injury or abuse/neglect

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4
Q

In older adults, which burn injuries are most common?

A

kitchen injury or smoking

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5
Q

Pediatrics

A
  • thin skin (increased severity)
  • large surface/volume ratio (rapid fluid loss & increased heat loss)
  • immature immunological response (sepsis risk)
  • *Always consider possibility of child abuse
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6
Q

Geriatrics

A
  • thin skin (increased severity)
  • decreased myocardial reserve (fluid resuscitation is difficult)
  • PVD & Diabetes (slow healing and impaired senses)
  • COPD (airway complications are increased)
  • Poor immunological response (sepsis risk)
  • higher risk for infection
  • diminished microcirculation
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7
Q

How to measure % mortality

A

Age + % BSA burned

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8
Q

3 Layers of the skins

A
  • Epidermis
  • Dermis
  • Hypodermis (subcutaneous)
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9
Q

Epidermis

A

protective barrier (prevents infection)

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10
Q

Dermis

A

cells that help create new ones (cell regeneration)

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11
Q

Hypodermis (subcu)

A

tissue, veins, arteries, nerves (regulates body temp)

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12
Q

Injuries to the skin increase the risk of:

A
  • hypovolemia (cannot maintain water balance)
  • hypothermia (cannot maintain temp)
  • infection (protective barrier is lost)
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13
Q

Thermal Burns

A
  • dry heat
  • moist heat
  • smoke & inhalation injury
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14
Q

Dry heat

A
  • contact burn (hot stove)

- flame burn (fire)

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15
Q

Moist heat

A

scald burn (hot water, oils)

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16
Q

Inhalation severity depends on

A
  • ignition source
  • size and diameter of particles
  • duration of exposure
  • solubility of gases
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17
Q

Complications of thermal injury

A
  • burn edema

- fluid loss

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18
Q

Burn edema

A
  • increased vascular permeability

- leak of fluids and proteins into interstitial space (fluid shifts)

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19
Q

Fluid loss

A

evaporation from burn wound

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20
Q

Chemical Burns

A

Acid, base or organic

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21
Q

Acid

A

not as severe; eschar prevents penetration into deeper tissues

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22
Q

Alkali/base

A

more severe; protein liquefaction occurs and allows penetration into deeper tissues (more damage)

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23
Q

Organic

A

can be absorbed systemically and lead to renal and liver damage

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24
Q

Inhalation-chemical burns

A

Lung injury and systemic absorption can occur; leading to pulmonary, CV, renal and liver damage

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25
Q

Tx for chemical burn

A
  • Get the chemical off

- wash immediately (remove clothing, socks and shoes too)

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26
Q

Chemical burn–NEVER attempt to:

A

neutralize the chemical

-can cause more burns from heat

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27
Q

Electrical

A

skin: best resistor

nerves & BV: best conductor

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28
Q

2 types of Electrical

A
  • Low voltage

- High voltage

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29
Q

Low Voltage

A

Alternating or direct

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30
Q

Alternating current

A

produces tetanus muscle contractions

**more severe

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31
Q

Direct current

A

hurls person away from current source

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32
Q

Currents–NEVER go near a patient until

A

current is off (could risk harming yourself)

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33
Q

High Voltage

A

Arc (flash burns or lightning)

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34
Q

S/S of electrical burns

A
  • vision problems
  • fractured bones
  • entry and exit burn
  • swollen tongue
  • arrhythmias
  • paralysis
  • respiratory problems
  • LOC
  • twitching muscles or seizures
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35
Q

Management of electrical burns

A
  • stop current first, then extinguish clothing fire
  • ABC
  • cardiac monitoring

**prolonged CPR is warranted

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36
Q

Management of electrical burns cont’d

A

monitor:

  • ECG
  • ultrasound of abdomen
  • chest x-ray
  • CT scan of head
  • Cardiac enzyme analysis
  • acidosis
  • release of myoglobin (muscle damage)
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37
Q

Radiation burn

A 
radiation therapy (damage to cells)
-background, industrial or lab accident
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38
Q

Radiation burn effects are evident in cells:

A
  • skin
  • blood vessels
  • GI lining
  • neurovascular syndrome
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39
Q

Radiation management

A

safety–protective equipment

-need for decontamination

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40
Q

4 Phases of body response to burns

A

Emergent (1)
Fluid shift (2)
Hypermetabolic (3)
Resolution (4)

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41
Q

Emergent

A
  • pain response
  • catecholamine release
  • tachycardia, tachypnea, hypertension, anxiety
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42
Q

Fluid shift

A
  • 18-24 hrs

- damaged cells initiate inflammatory response (massive edema)

43
Q

Hypermetabolic

A
  • days to weeks

- large increase in the body’s need for nutrients as it repairs

44
Q

Resolution phase

A
  • scar formation

- rehabilitation and progression to normal function

45
Q

1st 24 hours after injury

A

Ebb Phase occurs

46
Q

Ebb phase goal

A

to conserve volume and energy for recovery and repair; this leads to hypofunction/hypovolemic shock

47
Q

Hypofunction manifestations

A
  • hypotension
  • low CO
  • metabolic acidosis
  • hypoventilation
  • hyperglycemia
48
Q

Flow Phase (resuscitation)

A

gradual increase in:

  • CO
  • HR
  • oxygen consumption
  • increase in temp
49
Q

Burn injuries effect:

A
  • cardiovascular
  • pulmonary
  • renal
  • nutrition
  • GI
50
Q

Cardiovascular

A
  • decreased CO
  • decreased volume (burn shock)
  • decreased perfusion to organs and periphery
  • ST & T changes (electrical)
  • dysrhythmias
51
Q

Pulmonary

A
  • increased PVR, PAP, PAOP
  • pulmonary edema
  • decreased diffusion
  • circumferential chest burns (eschar stiffness affects chest expansion)
  • inhalation injury
52
Q

Renal

A

Risk for Rhabdomyolysis/Myoglobinuria (reddish-brown urine indicative of muscle damage)

53
Q

If myoglobin is present in the urine

A
  • adequate UO of 0.5-1mL/kg/hr is needed to prevent renal failure (IV fluids)
  • mannitol used to increase diuresis and promote clearance of myoglobin
  • alkalize urine to prevent crystalization of tubules (obstruction) by giving Sodium bicarb 50mEq IV
54
Q

Nutrition

A
  • Enteral nutrition needs to be implemented within 24 hours after injury
  • high calories, protein, glucose control
  • enteral preferred (maintains GI motility)
55
Q

Things to monitor with nutrition

A

-wound healing
-weight
-protein and prealbumin levels
(is it working?)

-enteral: residual & BM

56
Q

GI

A
  • Curling’s ulcer (gastroduodenal injury from reduced perfusion but increased acid production)
  • 1st 24 hours after burn (reduced GI bf and mucosal damage)
57
Q

Curling’s Ulcer tx

A
  • PPI
  • H2 blockers
  • early enteral nutrition
  • mucoprotectants

**monitor for sudden drop in hgb or heme positive stool

58
Q

Depth of Burn injury depends on:

A
  • source/type
  • temperature
  • duration of exposure
59
Q

Burn classifications

A
  • 1st degree (partial thickness)
  • 2nd degree (superficial partial thickness or deep partial thickness
  • 3rd degree (full thickness)
  • 4th degree (full thickness)
60
Q

1st degree (partial thickness)

A
  • erythema (redness)
  • no blisters
  • heals without intervention (3-5 days by sloughing)
  • no scarring
  • painful

**Think sunburn

61
Q

2nd degree (superficial partial thickness)

A
  • pain
  • blister
  • moderate edema
  • heals with re-epithelialization (10-14 days)
  • no scarring
  • potential for hypo/perpigmentation
62
Q

2nd degree (deep partial thickness)

A
  • red/white mottled skin
  • significant edema
  • pain or no pain
  • heals with skin graft (2-3 weeks or more)
  • potential scarring
63
Q

3rd degree (full thickness)

A
  • full skin destroyed
  • white, leathery appearance
  • muscle and bone may be destroyed
  • painless
  • no cap refill
  • skin graft or flap
64
Q

4th degree (full thickness)

A
  • subdermal
  • penetrates deep tissue, fat, muscle, bone
  • charred and dry
  • immediate professional tx (graft, amputation)
  • no sensation
65
Q

Wound conversion

A

progression of burn to a deeper injury

  • increased depth of wound
  • viable tissue may become non-viable
66
Q

Wound conversion causes

A

due to:

  • inadequate fluid resuscitation
  • infection
  • hypothermia
  • external pressure
67
Q

3 Burn zones

A
  • coagulation (immediately nonviable)
  • stasis (may become nonviable)
  • hyperemia (viable)
68
Q

Assessment of burns

A
  • TBSA

- used to determine fluid requirements and nutritional needs

69
Q

3 Methods of burn assessment

A
  • Wallace Rule of 9s
  • Lund & Browder chart
  • Rule of palms
70
Q

Rule on Nines

A

add all of the percentages, based on their locations of injury

71
Q

Lund & Browder chart

A

Adjusts TBSA for age; a child’s body is proportioned differently than an adult’s.

72
Q

Rule of Palms

A

use of hand as a tool to measure burn surface areas which are < 15%

73
Q

Indications for intubation (Airway)

A
  • oropharyngeal erythema/swelling on direct visualization
  • persistent cough, stridor, wheezing, or hoarseness
  • deep facial or circumferential neck burns
  • nares with inflammation or singed hair
  • carbonaceous sputum or burnt matter in the mouth or nose
  • blistering or edema of the oropharynx
  • depressed mental status, including evidence of drug or alcohol use
  • respiratory distress (dyspnea, tachypnea)
  • hypoxia or hypercapnia
  • elevated carbon monoxide and/or cyanide levels
74
Q

Breathing Assessment

A

-Circumferential full thickness burns may impair ventilation (eschar is thick)
-Blast injuries can cause pneumothorax & lung contusions
-chemicals (plastic) can cause a chemical pneumonitis & cyanide poisoning
-Carbon monoxide poisoning
(if COHb > 15 – 40% ventilate)

75
Q

Upper airway inhalation injury

A
  • supraglottic
  • inhalation of hot air
  • upper airway edema peaks at 24-48 hrs
  • singed hair, facial burn, stridor

**monitor for obstruction and administer O2 and elevate HOB

76
Q

Lower airway inhalation injury

A
  • infraglottic
  • inhalation of toxic gas and chemicals
  • injury to mucosa and cilia (leads to tracheobronchitis)
  • *may present w/o symptoms at first
  • then cough, hypoxemia, chest tightness, adventitious lung sounds
77
Q

Early tx of inhalation injury

A
  • focused resp assessment
  • humidified oxygen
  • ET tube intubation
  • pulmonary hygeine (TCDB, IS)
  • monitor ABGs, CXR, bronchoscopy
78
Q

Cyanide poisoning

A
  • from plastic
  • prevents O2 release from blood to tissues (anaerobic metabolism occurs)

**increased lactate and anion gap

79
Q

Carbon monoxide toxicity

A

Carbon monoxide binds with Hgb

-SaO2 and SpO2 will be falsely high (give oxygen, monitor COhgb levels)

80
Q

Interventions for burns

A
  • circulation

- fluid resuscitation

81
Q

Circulation

A
  • monitor BP, HR, color of unburnt skin (baseline)
  • 2 large bore IVs
  • doppler exam of burnt extremities
82
Q

Fluid Resuscitation

A
  • **critical to prevent burn shock

- maintain organ perfusion (MAP >90)

83
Q

Parkland formula (fluid resuscitation) 24 hour

A

4mL of LR x % TBSA x kg

give half over the first 8 hours, remainder over 16 hours

84
Q

Fluid-monitor:

A
  • Hgb & Hct
  • urine osmolality
  • serum electrolytes
  • creatinine and BUN
  • CVP
  • Arterial BP
85
Q

Criteria for Burn unit transfer

A
  • greater than 10% TBSA
  • burns that involve the face, hands, feet, genitalia, perineum, or major joints
  • third degree (full thickness) burns in any age group
  • electrical burns, including lightning injury
  • chemical burns
  • inhalation injury
  • burn injury in patients with preexisting medical conditions
  • burns with trauma
  • children
86
Q

Escharotomy for burns:

A

incision through eschar to expose fatty tissue below (circumferential burns)

87
Q

Fasciotomy

A

For burn-induced compartment syndrome: within muscle compartment, incision to the fascia
(circumferential burns)

88
Q

indications for escharotomy

A 
cyanosis
pain
paresthesia
impaired capillary refill
decreased peripheral pulses
89
Q

Wound care for burns

A
  • ABC and stabilization first
  • Stop burning process
  • Cleanse wound - sterile saline
  • *No ointment if being transferred
90
Q

Types of debridement

A
  • mechanical (irrigation)
  • biosurgical (maggot debridement)
  • chemical (enzymes)
  • surgical (fascial or tangential excision)
91
Q

signs of burn wound infection

A
  • early separation of burn eschar
  • color change
  • increased exudate
  • increased pain or depth
92
Q

Tangential Excision

A

removal of thin slices of burned skin
-used for deep dermal burns and 3rd degree

**high risk for blood loss

93
Q

Fascial Excision

A

removes all layers of eschar and underlying tissue to level of fascia

  • if subcu fat is burned
  • > 60% FTB
94
Q

FTSG

A

used for elbows, hands, and scapula

  • not cosmetically appealing
  • durable (less risk of contracture)
95
Q

STSG

A

thinner
harvested with dermatome
meshed to cover larger area
more cosmetic

96
Q

meshed grafts

A
  • allows escape of subgraft fluid

- increases size of available tissue

97
Q

2 types of dressings

A
  • open method

- closed method

98
Q

open

A
  • silver sulfadazine
  • no dressing
  • common with face, head, neck burns
99
Q

closed

A
  • sooth and protect wound
  • reduces pain
  • absorbent
100
Q

Steps to wound care

A

1-remove bandage
2-debridement
3-sterilization
4-reapply bandage

101
Q

Rehabilitative phase

A
  • pain control
  • pruritis
  • psychosocial needs
  • physical mobility
  • scar management
102
Q

physical mobility

A

-early ambulation

103
Q

Scar management

A
  • compression garments

- skin conditioning

High Acuity (1 decks)

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